CITY OF DICKINSON MUNICIPAL COURT

CITY OF DICKINSON MUNICIPAL COURT
APPLICATION FOR TIME PAYMENT OR EXTENSION
SOLICITUD PARA LA EXTENSION DEL PAGO DE MULTA Y GASTOS DE TRIBUNAL
(Please complete all information and please print legibly) Phone numbers are verified while at the windows.
(Por favor complete toda la informacion y imprima de forma legible.) Numeros de telefono se verifican en las ventanas
Name: ______________________________________________________________________________________________________
Last (Appellido)
First(Primer Nombre)
Middle (Segundo Nombre)
Date of Birth:______________________ Drivers Lic. or Id No._____________________ Social Security No._________________
(Fecha de Nacimiento)
(Numero de Licencia O de Id)
(No. De Seguro Social)
Address: ___________________________________________________________________________________________________
Direccion Street Number/Name
Apt./Lot
City, State, Zip Code
(Calle)
(No. de Apartmento)
(Ciudad, Estado, Codigo Postal)
Mailing Address:______________________________________________________________________________________________
Direccion de envio
P.O. Box or Street
Apt.
City, State, Zip Code
(Calle)
(No. de Apartmento)
(Ciudad, Estado, Codigo Postal)
Telephone Number: ________________________________________Cell Phone #:________________________________________
Telefono De su Casa
Numero Cellular
Employer: ____________________________________________________ Job Title: _____________________________________
Empleo:
Name/Nombre
(Clasa de Trabajo)
Employer's Address: __________________________________________________________________________________________
Address/Direccion
City, State, Zip Code\ (Ciudad, Estado, Codigo Postal)
Salary: $____________ per ____________ Employer's Telephone Number: _________________________________________
(Sueldo Libre)
(Por)
(Telefono de Trabajo)
List of Name, Address & Phone Humbers of Two (2) Personal Reference Not Related to You:
(Lista de nombre, las direcciones, y numbero de telefono de los referencias personales que no sean familiars de usted):
Name \Nombre
Nombre
Street Address Apt.
Calle|No. de Apartmento
City, State, Zip
Phone
(Ciudad, Estado, Codigo Postal) Telefono #
Name \Nombre
Nombre
Street Address Apt.
Calle|No. de Apartmento
City, State, Zip
Phone
(Ciudad, Estado, Codigo Postal) (Telefono #)
Bank Account (Check all that apply) ___ Checking
____Saving ____Other:___________ Available Balance:$______________
(Cuenta Bancaria)
Cuenta Corriente bancaria)
(Ahorros)
(Otro)
(Saldo\Balance disponible)
Obligation (OBLIGACION):
List All Your Creditors (Mortgage Companies, Banks, Credit Cards, Finance Compaines, Department Stores,etc)
Lista de Creditors Y Deudas):
_______________________________________________
Compayn Name
(Nombre de Compania)
Balance Owed
(Balance de pagos)
_______________________________________________
Compayn Name
(Nombre de Compania)
$___________________________________
$___________________________________
Balance Owed
(Balance de pagos)
__________________________
Payment Amount (Month
( Pago Mensual)
__________________________
Payment Amount (Month
( Pago Mensual)
By my signature below the information above is true and correct to the best of my knowledge:
Con mi firma abajo declaro que esta informacian es verdad y es correcto con el mejor de mi cono
cimiento:
WARING: FILING FALSE INFORMATION WITH THE COURT IS A CLASS A MISDEMEANOR
PUNISHABLE BY UP TO ONE YEAR IN JAIL AND MAXIMUM FINE UP TO 4, 000.00
ADVERTENCIA: LA PRESENTACIÓN DE INFORMACION FALSA CON EL TRIBUNAL ES UNA
CLASE A DELITO MENOR PUNIBLE CON HASTA UN AÑO DE CÁRCEL Y UNA MÁXIMA
MULTA HASTA $4,000.00
___________________
DATE (Fecha)
______________________________________________________
Signature (Firma)
Payment of Fine and Court Costs
A fine is part of your punishment for the crime committed. Court costs are part of the expense of legally
processing your case. Failure to pay can either RESULT IN YOUR ARREST, CONFINEMENT, AND/OR A
HOLD BEING PLACED ON YOUR DRIVER’S LICENSE. If a warrant is issued for your arrest, you will be
held in the City Jail until someone has paid the balance in full on your behalf, post a bond, if applicable, or
until you have served out the balance in jail.
General Processing
IF YOU LEAVE WITHOUT MAKING EITHER PAYMENT IN FULL OR PAYMENT ARRANGEMENTS, YOU WILL BE
IN VIOLATION OF YOUR COURT ORDER AND SUBJECT TO ARREST.